Newborn infants are born with an immature innate immunity. They are less likely to develop anaphylaxis since their immune system is weaker than older infants and children. There are only a few reports of side effects after vitamin K injection in neonates although prophylaxis against hemorrhagic disease of the newborn with this drug has been in routine practice in all over the world for many years. We herein report a case of anaphylactic shock developing after the intramuscular administration of vitamin K1 in a newborn. To our knowledge, this patient is the first case of neonatal anaphylactic shock developing due to intramuscular administration of vitamin K1. We suggest the clinicians should be aware of this possibility of potentially fatal adverse effect occurring with intramuscular administration of vitamin K1.

PURPOSE:Five cases of sound-alike, look-alike, neonatal medication-dispensing errors and their resolution are reviewed.

SUMMARY:In 2008, there were five cases in which look-alike or sound-alike neonatal medication-dispensing errors occurred at our institution. A mix-up between neonatal and adult or pediatric products occurred in four of the five cases. Three of the five errors resulted in near misses with the potential to cause harm. The other two errors reached the patients but did not cause harm. The medication mix-ups involved adult and neonatal phytonadione injectable emulsion, sodium citrate injection and vancomycin-heparin combination injection, adult tetanus-diphtheria-acellular pertussis and infant diphtheria-tetanus-acellular pertussis (DTaP) vaccines, Haemophilus B and DTaP vaccines, and cisatracurium and vecuronium. Each error exposed weaknesses in the system of neonatal medication storage, labeling, delivery, knowledge, and administration documentation at our institution. Resolution of system problems was made possible by a collaborative approach and involved reorganizing shelving used to store neonatal medications; using a differently colored labeling scheme for products whose syringes were nearly identical; implementing changes to the infant vaccine ordering, storage, dispensing, and documentation systems; and instituting centralized and decentralized pharmacist review of pharmacy technician automated dispensing cabinet-filling activities.

CONCLUSION:An institution providing services to both neonatal and adult patients experienced five cases of medication-dispensing errors with look-alike or sound-alike medications. Multidisciplinary collaboration within the system helped the pharmacy identify, resolve, and prevent errors related to medication storage, labeling, delivery, knowledge, and administration documentation.

Vitamin K deficiency in infants can cause life-threatening haemorrhages. To prevent this, neonates in the Netherlands receive an oral dose of 1 mg vitamin K directly after birth. In addition, because breast milk contains little vitamin K, breast-fed infants receive a daily dose of 25 micrograms the first three months. Of three female infants aged 4 weeks, 5 months and 3 months, respectively, two developed an intracranial haemorrhage, which caused death in one. In two cases there were signs of a bleeding tendency, but no tests were done because the patients appeared healthy otherwise. The underlying resorptive disorders, cholestasis and fat malabsorption, caused few symptoms and were discovered only after a vitamin K deficiency bleeding had occurred. In an infant with a bleeding tendency, one should consider the possibility of vitamin K deficiency, even if adequate prophylaxis has been given.